Provider Demographics
NPI:1073611075
Name:JUDEAN INC
Entity Type:Organization
Organization Name:JUDEAN INC
Other - Org Name:LICHTY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-274-6114
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:MN
Mailing Address - Zip Code:56183-0127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 1ST AVE
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:MN
Practice Address - Zip Code:56183
Practice Address - Country:US
Practice Address - Phone:507-274-6114
Practice Address - Fax:507-274-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2605153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2409173OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN932757600Medicaid
0739340001Medicare NSC